Employment Application for Technologies Division This Application must be filled out entirely Your Name:* Address:* City:* State:* Zip Code:* Primary Phone Number:* Secondary Phone Number: Your Email:* Rate of Pay Requested:* Applying for Area Location of:* TucsonPhoenixOther (Please Specify) If Other, Please Specify: Position you are applying for:* Telecommunications TechnicianTelecommunications Wireman List how many years of total experience you have in the electrical trade:* Are you willing to travel out of town to work?* YesNo List any days/hours you are UNABLE to work or reasons you might not other than sickness and why:* For Insurance and Security Clearance Purposes Do you have a valid Driver’s License?* YesNo Driver's License Number:* State:* Expiration Date:* Do you have a clear driving record for the last 3 years?* YesNo Do you have a CDL?* YesNo Have you had a DUI or other serious infraction on your driving record?* YesNo If Yes, Please Explain: Have you ever been convicted of a Felony or Misdemeanor other than a Traffic Violation? YesNo If Yes, Please Explain: Do you have your own personal and reliable transportation?* YesNo Do you have insurance on your vehicle?* YesNo How did you hear about this job? Have you ever worked for Kelly Energy Inc. before?* YesNo If Yes, When? List any relatives or friends working for Kelly Energy Inc. now: Personal References Name:* Relationship:* Phone Number:* Name:* Relationship:* Phone Number:* Name: Relationship: Phone Number: Education(s) High Schoo: Date Graduated: University/College: Date Graduated: Degree/Major: Military Services:* YesNo Branch/Dates of Service/MOS/Other Information: Are you BICSI Certified?* YesNo If yes, what classification? Are you certified by another accredited program?* YesNo If yes, what is the name of the program and your classification? Please mark the appropriate skills you are trained/qualified to perform: Cat 5, 5e, 5E+ and 6: InstallationTerminationTesting T-1 InstallationTerminationTesting Optical Fiber InstallationTerminationTesting Testing and System Certification with: Light Source/Power MeterOTDR Experience with Special Systems: Fire AlarmSecurityNurse/CellProgrammable Lighting Kelly Energy Inc. offers an accredited BICSI certification Program. Are you interested in applying for enrollment in this program? YesNo Please list any other schooling/skills/special training you have had: Employment History Employer (most current) 1:* Supervisor's Name:* Phone Number:* Starting Salary:* Ending Salary:* Starting Date:* Ending Date:* Job Title:* Duties:* Reason(s) for Leaving:* Employer 2:* Supervisor's Name:* Phone Number:* Starting Salary:* Ending Salary:* Starting Date:* Ending Date:* Job Title:* Duties:* Reason(s) for Leaving: Employer 3: Supervisor's Name: Phone Number: Starting Salary: Ending Salary: Starting Date: Ending Date: Job Title: Duties: Reason(s) for Leaving: Resume Please note: A Resume does NOT take the place of this application. Any Resumes received without an application will not be considered for employment. Applicant's Statement I certify that my answers on this application are true and correct. If employed, I understand that any false or misleading information or statements given in my application or during my interview may result in my immediate dismissal. By signing below, I hereby authorize Kelly Energy Inc. to verify the information I have given on this application and to contact any previous employers and references listed on this application unless specifically noted below: (List anyone you do not want us to contact, and the reason why). Applicant's Digital Signature:* Date:*